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Case Report Open Access Chen et al., J Diabetes Metab 2012, 3:3 DOI: 10.4172/2155-6156.1000185 Volume 3 • Issue 3 • 1000185 J Diabetes Metab ISSN:2155-6156 JDM, an open access journal Keywords: Acute fatty liver of pregnancy; Diabetes mellitus Introduction Acute Fatty Liver of Pregnancy (AFLP) is a rare life-threatening complication of pregnancy. e estimated incidence of AFLP was 5 cases per 100,000 pregnancies and case fatality rate was 1.8% in a prospective study [1]. Reported maternal mortality has ranged from none to 11% [2-4]. Non-alcoholic Fatty Liver (NAFL) is very common in type 2 diabetes [5]. However, the occurrence of AFLP in type 2 diabetes has not been previously reported. AFLP occurring in women with diabetes could be very dangerous. We report a rare case of AFLP in a woman with type 2 diabetes and raise an issue on the linkage between type 2 diabetes and AFLP with a brief literature review. Case Report A 35-year-old woman in her 35th week of pregnancy was hospitalized via the emergency department with nausea, vomiting, and malaise for 1 week in February 2011. She had been diagnosed as type 2 diabetes in January 2010 with fasting sugar 245 mg/dl, Hb A1c 9.9% (HPLC 4.3 - 6.5%), and C-peptide 1.38 nmol/l (normal 0.9-4.0 nmol/l) . Her body height was 160 cm, weight 58 kg, Body Mass Index (BMI) 22.6 kg/m 2 and blood pressure 122/87 mmHg. Her mother has type 2 diabetes under oral hypoglycemic agent treatment. Her younger brother and sister are well without other autoimmune disease. Although Latent Autoimmune Diabetes in Adult (LADA) is possible, we cannot prove it without islet autoantibodies. Since then, she had been treated with premixed insulin in preparing for a planned pregnancy which was diagnosed in June 2010, her last menstrual period having occurred in May. A1C levels were 7.4% and 7.3% in July and September. She was doing well until 1 week before visiting the emergency department due to persistent symptoms despite prior visits to the obstetrical and medical outpatient clinics. On physical examination, she was alert, appeared ill, and not icteric. Laboratory data were aspartate aminotransferase (AST) 550 U/l ( normal 0-35 U/l), alanine aminotranferease (ALT) 651 U/l (normal 0 - 32 U/l), alkaline phosphatase (ALP) 1106 U/l ( normal 125 - 250 U/l), LDH 218 (normal 98 - 192 U/l) total bilirubin (T Bil) 1.4 mg/ dl (normal 0.2 - 1.2 mg/dl) , creatinine (Cr) 1.39 mg/dl (normal 0.8 - 1.3 mg/dl), activated partial thrombin time (APTT) 39.4 s (normal 28.2 s) and prothrombin time (PT) 13.1 s (normal 10 s),. Viral hepatitis A, B, and C were excluded by negative results for anti-HAV IgM, HBsAg, and anti-HCV Ab. Gallbladder stones were shown with abdominal ultrasound. Aſter hospitalization, diabetes insipidus was also diagnosed and treated with DDAVP for a short period. Her condition progressively deteriorated with elevated levels of Cr to 1.53 mg/dl and 1.93 mg/dl, ALP to 1168 U/l, GPT to 704 U/l, and T Bil to 2.2 mg/dl and 3.9 mg/ dl, as shown in Figure 1. Elevated plasma uric acid 9.9 mg/dl (normal 2.4 - 6.0 mg/dl), lower albumin level 2.7 g/dl (normal 3.5 - 5.5 g/dl), and calcium 7.1 mg/dl (normal 8.4 - 10.4 mg/dl) were also found. e following days of hospitalization, PT was slightly increased to 13.8 s. Because of this, an emergency cesarean section was performed on the 5th day of hospitalization and a healthy 2665 gm male baby was delivered. Her condition improved dramatically with lowering of AST to 34 U/l, ALT to 62 U/l, ALP to 747 U/l, and T bil to 1.8 mg/dl (Figure 1). Direct bilirubin (D bil) was 0.7 mg/dl (normal 0 - 0.4 mg/dl). Her postpartum condition was good in March 2011 with A1C 6.5%. Fatty acid oxidation screening was normal in the baby. Her C-peptide level was 1.54 nmol/l in August 2011. *Corresponding author: Dr. Kwang-Wen Chen, Department of Internal Medi- cine, St Paul’s Hospital, No 123, Chien-Hsin St., Taoyuan City, Taiwan, Tel: 886- 3-3613141; Fax: 886-3-3773373; E-mail: [email protected] Received February 21, 2012; Accepted April 22, 2012; Published April 26, 2012 Citation: Chen KW, Yang CC, Li YM, Lee YS (2012) Acute Fatty Liver of Pregnan- cy in a Woman with Type 2 Diabetes. J Diabetes Metab 3:185. doi:10.4172/2155- 6156.1000185 Copyright: © 2012 Chen KW, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Acute Fatty Liver of Pregnancy in a Woman with Type 2 Diabetes Kwang-Wen Chen 1 *, Cherng-Chia Yang 2 , Yuan-Ming Li 3 and Yuan-Shun Lee 4 1 Department of Internal Medicine, St Paul’s Hospital, Taiwan 2 Department of Obstetrics and Gynaecology, St Paul’s Hospital, Taiwan 3 Department of Laboratory, St Paul’s Hospital, Taiwan 4 Department of Pediatrics, St Paul’s Hospital, Taiwan Abstract We report a 35 year-old woman with type 2 diabetes who developed acute fatty liver of pregnancy in her 35th week of pregnancy. She presented with nausea, vomiting, elevated transaminases, elevated bilirubin, renal impairment, and coagulopathy. Her condition improved dramatically after an emergency cesarean section. ALP ALP U/L ALT ALT AST AST T-Bil Cr C/S 1106 1168 890 747 62 194 415 704 651 550 42 34 1.8 2.6 3.9 2.2 1.4 1.39 1.83 1.93 1.12 0.74 1200 800 400 0 -400 Day 1 Day 4 Day 5 Day 7 Day 11 T-Bil Cr 20 15 10 5 0 mg/dL Figure 1: J o u r n a l o f D i a b e t e s & M e t a b o l i s m ISSN: 2155-6156 Journal of Diabetes and Metabolism
